Diet, growth, nutritional status and predictors of severity of feeding difficulties in autistic children with co-occurring pediatric feeding disorder

Background: Feeding difficulties are commonly reported in autistic children. However, there is limited data on the presentation, severity, and impact of feeding difficulties in autistic children in Asia. Aims: To describe the dietary patterns, growth and nutritional status of autistic children with pediatric feeding disorder (PFD), and identify factors associated with more severe feeding difficulties. Study design: A retrospective review of electronic medical records. Subjects: Autistic children (aged between 0 and 18 years) with PFD, who attended a multidisciplinary feeding clinic between August 2013 and December 2022. Outcome measures: The children's parents provided a 3-day food diary, which was verified by the dietitian and analyzed for their nutritional content using Foodworks 10 Professional. Food selectivity was classified as mild, moderate or severe, based on the number of food groups accepted and the absolute number of foods accepted in each group. Information regarding demographics, height, weight, medical information, developmental history (autism diagnosis, cognition, adaptive skills) and relevant nutritional bloodwork were collected. Parents also completed two validated questionnaires (the Behavioral Pediatrics Feeding Assessment Scale (BPFAS), which assessed childhood mealtime behaviors; and the Caregiver Feeding Style Questionnaire (CFSQ), which determined caregiver/ parental feeding styles). Factors associated with higher BPFAS total frequency scores (TFS) (representing more severe feeding difficulties) and food selectivity were analyzed. Results: There were a total of 98 patients (82 males), with mean +/- SD (range) age of 59.2 +/- 27.5 (17-169) months. They had mild (19.4 %), moderate (22.4 %) and severe (58.2 %) food selectivity, respectively. While the majority had normal weight (84.7 %) and height (88.8 %) for age, 69.4 % had diets deficient in calories, macronutrients or micronutrients (iron, calcium). Comparison between groups according to parental feeding style found that there was a significant difference in BFPAS TFS between different parental feeding styles (p < 0.001). Post-hoc testing revealed that parents who reported an authoritarian parental feeding style on the CFSQ were significantly more likely to report higher frequencies of difficult feeding behaviors on the BPFAS (98.3 +/- 15.8), while an uninvolved parental feeding style was associated with the lowest BPFAS TFS (80.9 +/- 11.0), Bonferroni-adjusted p < 0.001; indulgent (p = 0.012) and authoritative (p = 0.096). Intellectual impairment and Malay ethnicity were associated with more severe food selectivity [adjusted odds ratio 123.7 (95 % CI 3.09-4945.4, p = 0.01) and 38.0 (95 % CI 1.35-1074.18, p = 0.03)], respectively. Conclusions: In this retrospective cohort, autistic children with PFD were at significant nutritional risk despite demonstrating normal growth patterns, with specific patient profiles being associated with more severe feeding difficulties.